The emergence of the Convenient Care Clinic

April 4, 2007 An interesting development in the health system in the U.S. of recent times has been a new type of health facility that is beginning to pop-up at local drug stores, discount stores and various supermarkets. In the store's local pharmacy, many establishments have set up mini-clinics. Operating specifically in high-traffic retail outlets with accessible pharmacy services, these clinics provide routine, non-emergency services to walk-in patients at affordable prices seven days a week. These mini-clinics cost half of what patients typically pay for a regular doctor's visit and are roughly one-sixth the cost of an emergency room visit. Patients who visit these mini-clinics are treated by a family nurse practitioner or a physician's assistant – both of whom can write prescriptions and perform a full exam. Although mini-clinics do not handle chronic illnesses, they are ideal for ailments like strep throat, sinus infections or common colds and with no appointment necessary, extended hours, and seven days a week, the approach is more in keeping with modern business practices than the unyielding, inefficient and expensive traditional health system. As Charles Darwin said: “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.”

Mini-clinics accept insurance co-pays, Medicare and Mdicaid, they’ll send a report to your primary care doctor and if you don’t have one, they can recommend one in your neighborhood.

Since the first Convenient Care Clinic opened in 2000, the Convenient Care industry has grown quickly. Today there are over 200 such clinics operated by over a dozen companies across America. In September 2006, the Convenient Care Association (CCA) was founded to represent this new form of healthcare facility. The CCA's mission is to strengthen and advance the Convenient Care model of health care.

The need for accessible, affordable, quality health care has never been greater. The CCA has a white paper on the role of the Convenient Care Clinic (CCC). The following two chapters from the white paper are below. The full white paper is available here.

Introduction

Over the past year, the media has extensively covered the emergence of retail-based CCCs. Many have written about the expectation that retail health clinics will “profoundly affect health care delivery by providing an alternative site for basic medical needs.” CCCs have been called a “disruptive innovation” because they are consumer-driven and they serve as a response to many health care patients who “are frustrated with the conventional health care delivery system,” which often provides little access to basic health care services when people need it the most. While the CCI still has yet to fully establish itself, the clinics have shown tremendous potential in providing affordable, accessible and quality health care to consumers who otherwise would have to wait hours, days, or even weeks for the care they deserve. Other alternatives include seeking costly, time-consuming emergency room care for illnesses that could have been prevented if basic health care services had been accessible.
Ownership of convenient care clinics varies. Some of them are privately held, and others are run through health systems, or non-profit organizations. Most have a medical director involved at the highest level of the organization and some have nursing leadership. Several of the leading CCCs have both a medical and nurse practitioner officer who work collaboratively overseeing the medical scope of practice and quality care of the organization.

In addition to highly qualified PAs and physicians, CCCs are usually staffed by Family Nurse Practitioners (FNPs), who provide high-quality health care services for episodic, common family ailments. Services include diagnosis and treatment of the most common health problems experienced by patients, including: sore throats, immunizations, and preventive health care screenings. Evidence to date has shown that “clinics do not increase overall demand for medical services, an initial concern expressed by the medical and insurance community; rather, they offer an alternative for consumers [at all socio-economic levels] facing access problems within the conventional health care system.” To date, consumers have expressed high levels of patient satisfaction with the services provided by NPs, PAs and physicians and the convenience of using a CCC.
The CCI plans to expand across the nation, rolling out thousands of clinics over the next few years and ultimately increasing access for all Americans. However, CCI leaders, dedicated to providing the highest quality care, are determined to ensure that the convenient care movement is recognized as one of high quality and integrity. Thus, in the summer of 2006, leaders and stakeholders of the new and emerging retail-based CCI convened a Summit to shape the future of this new industry. The information, data and input from the Summit participants have resulted in this CCI White Paper. The purpose of this paper is to provide background and historical information on the industry along with education about the largest group of providers in the CCC, NPs, as the care providers, to describe the role of the new consumer-driven model of care and to lay out future directions for the CCI.
History & Background of the Convenient Care Center Model

While the convenient care centers are a relative new provider type in the U.S., the concept of highly trained nurses as accessible health care providers dates as far back as the 1890s when visionaries like Lillian Wald founded the Henry Street Settlement. CCCs began in 2000, when the first in-store clinics appeared in Minneapolis-St. Paul, operated by QuickMedx. These first health clinics initially saw a very limited number of illnesses and accepted only cash for services. Today there are over a dozen companies across the country that have formed to provide health care services, to individuals and families, for common illnesses. The clinics have progressed to forming contracts with health insurance companies, while also accepting cash payments for a visit. A 2005 Wall Street Journal Online Interactive Health-Care Poll showed that 83% (N=2245) of adults strongly or somewhat agree that companies can provide onsite health services at retail stores, and that 78% (N=2245) of people felt strongly that retail-based clinics provide a convenient way for people to get basic medical services.

There are an estimated 200 CCCs throughout the United States today. The clinics are located in convenient locations such as drug stores, food stores and other retail settings with pharmacies, enabling patient accessibility and making it easy and convenient for patients to get their needed prescriptions filled onsite. Therefore, it seemed suitable to call this revolution in health care delivery the “Convenient Care Industry.”

The health care clinics range in size from one exam room to multiple exam rooms, with sinks and exam tables. The clinics generally occupy 200-500 square feet and are outfitted with all the necessities of an outpatient health care office. Federal laws require that owners and operators of the clinics rent retail space at fair market value. The NPs who staff the CCCs work for the operators of the clinics and have a collegial relationship with the pharmacy staff of the retail setting. The average cost to set a center up is approximately $75,000, excluding payroll and corporate overhead costs. Most of the clinics are open seven days a week – twelve hours a day during the workweek and eight hours on Saturday and Sunday. These hours are generally more convenient than a traditional doctor’s and primary care provider’s office. The health clinics are usually busier on the weekends, in the evening and at lunchtime reflecting their convenience and consumer-focus. Most of the clinics see patients 18 months of age and older and visits generally take 15-25 minutes for diagnosis and treatment. CCCs believe strongly in the transparency of medical costs; thus, the clinics visibly post their health care services, treatment costs and information on NPs as providers of care. The basic cash cost for a visit to a CCC ranges from $40-$70. Additional charges may also be assessed for diagnostic screenings and immunizations. Many insurance plans cover visits to CCCs, allowing the patient to pay their co-pay.

The clinics are primarily staffed by NPs, along with physician assistants (PAs) and physicians tied to a corporate entity. The NPs and/or PAs and in some instances physicians provide all the medical care and also handle some administrative functions. Some of the CCCs also have medical assistants who aide the NPs or physicians and help with patient flow. Most clinics use proprietary software systems, electronic health records and technology to enhance the patient experience and continuity of care within the medical community.

In general, the CCCs have written guidelines and established protocols that the providers use to assist with their decision-making process and to ensure the highest level of patient care and satisfaction. For example, when a patient arrives at a clinic, they will register to be seen, sometimes using a touch-screen computer terminal (similar to an airline self-check-in kiosk), where they will enter basic demographic information and the reason for their visit. This sign-in process is the beginning of the patient’s Electronic Health Record. In some cases, this information is then immediately transmitted electronically to a computer terminal inside the treatment room, where a provider is notified of a patient waiting to be seen. Once the patient is escorted to the exam room, the provider validates the information provided by the patient at check-in and enters additional medical information about the patient's symptoms and conditions, as well as any pertinent medical history.

NPs perform CLIA-waived lab tests, write prescriptions if needed, and transmit prescriptions electronically to the store pharmacy or any pharmacy that accepts electronic scripts. Or, if the patient prefers, a printed script can be given at the conclusion of the visit and hand carried to the pharmacy. To ensure continuity of care, the patient is given a copy of their health record at the end of the visit, which they are able to share with their primary health care provider or any other member of the health care team. In many cases, operators of CCCs simply make the patients’ Personal Health Records available to their PCPs, referral physicians or hospitals, pending patient request and approval. This information can also be faxed to any provider that the patient designates to further enhance the continuity of care process. At this time, records cannot be e-mailed due to the unsecured method of transmission. However, the longer-term goal is to exchange the patient’s health record electronically with the provider the patient authorizes and chooses. As CCCs continue to work with physicians and other health care providers, and as relationships and technologies develop, safe and secure electronic sharing of records will be much more standard and common. In turn, patients will also be able to access their health record online.

Many physicians across the nation have partnered with CCCs in providing a collaboration and referral network system for patients that come to the clinics. Many of these physicians welcome the CCCs as an alternative for their patients. However, some medical groups opposed the formation of the CCCs, basing their objection on the fear that patients would not receive quality care or get integrated health care, and that NPs were not qualified or suited to work in an independent setting. However, others believed that the creation of the CCCs was spurred by patients’ desire for more convenient, affordable health care, and that CCCs represent a needed alternative for access to health care for patients.

To date, the American Academy of Family Physicians, American Medical Association and American Academy of Pediatrics, have responded to the formation of the CCI by calling for increased regulation of the practice and industry. They have published principles and guidelines in an attempt to regulate CCI operations and to address the quality of care delivered. The American College of Nurse Practitioners has adopted a resolution in support of the CCI and its role in improving access to care. The CCI industry welcomes the input of such organizations to work in collaboration with the CCI to contribute to the shaping of quality care and accessibility within the delivery system. Several CCCs have reached out to the greater medical and nursing community, to encourage their participation in a meeting on access, integration, and most importantly, how they can unite together to serve the needs of patients. The demand for this new model of care arises out of an urgent issue recognized by so many across the entire spectrum of healthcare providers — that of access to care. The need for continued dialogue between the CCI and the medical/nursing community is critical. The CCI looks forward to working with medical and nursing organizations, and the local communities where they operate to ensure integrated patient care and the delivery of a quality patient healthcare experience.

Conclusion

CCCs have evolved at a time when our health care system is floundering. The focus of the CCI is quality, convenience and consumer choice. They have established standards, employ competent professional health care providers, and use ongoing quality improvement mechanisms, including the incorporation of evidence-based practices in the care of their patients. Health care delivery systems are changing in multifaceted ways and are constantly in flux. As Charles Darwin said: “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” CCCs have identified the need for change and are filling a niche by moving to bridge the chasm between a failing health care system and a rising new model of care that offers high quality, cost-effective, and timely health care.